Provider Demographics
NPI:1649222332
Name:DIMENNA, JOHN D (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:DIMENNA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 RIVERSIDE DR
Mailing Address - Street 2:STE 205
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13905
Mailing Address - Country:US
Mailing Address - Phone:607-798-7100
Mailing Address - Fax:607-798-0675
Practice Address - Street 1:161 RIVERSIDE DR
Practice Address - Street 2:STE 205
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905
Practice Address - Country:US
Practice Address - Phone:607-798-7100
Practice Address - Fax:607-798-0675
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY156366207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01084784Medicaid
NY01084784Medicaid
34864FMedicare ID - Type Unspecified